Referral to cardiac rehab must be improved

Implement systematic approach

Although research shows that cardiac rehabilitation programs, also known as secondary prevention programs, help improve the health and life expectancy of people with heart conditions, the referral rate is low.

Across the United States, about 20% of eligible patients are referred to cardiac rehabilitation, says Murray Low, EdD, FAACVPR, FACSM, president-elect of the Chicago-based American Association of Cardiovascular and Pulmonary Rehabilitation and director of four cardiac rehabilitation programs in New York State and Connecticut.

Low says in a recent study published by a group of researchers at Brandeis University in Waltham, MA, referral among states varies greatly. For example, only about 12% of eligible Medicare patients in New York State were referred to cardiac rehab. In Connecticut, it was slightly higher, with 19% referred.

To improve the numbers, new standards were created by the AACVPR, Dallas-based American Heart Association, and the Washington, DC-based American College of Cardiology. The AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services give details on referral and enrollment in programs, so no eligible cardiac patients fall through the cracks.

"The referral to cardiac rehabilitation for specific diagnoses or procedures should be automatic and systematic within a hospital," says Larry F. Hamm, PhD, FAACVPR, FACSM, the 2007-08 president of AACVPR and visiting professor and director of the Clinical Exercise Physiology Program in the department of Exercise Science at The George Washington University Medical Center in Washington D.C.

All the right boxes can be checked on a hospital discharge form, but if there is no follow-up, the patient may not enroll in a cardiac rehabilitation program. The cardiologist may forget to ask the patient at his or her next office visit.

A good way to make sure patients are encouraged to enroll is to initiate an automatic referral to a cardiac rehabilitation program. Then patients can be scheduled for an informational session and make an informed decision about whether they want to participate.

In addition, physicians must understand they need to directly refer their patients, says Richard Stein, MD, a spokesperson for the American Heart Association and director of the Urban Community Cardiology Program at New York University School of Medicine in New York City.

All other strategies, such as providing brochures or having the nurse discuss a program with the patient, have less impact than a physician giving a patient a direct recommendation, he says.

It's important that the recommendation be direct, says Stein. For example, the physician should state "the next important step in your health care is to go to cardiac rehabilitation" rather than making a general statement such as "all my patients go to cardiac rehabilitation."

The AACVPR is currently working on quality indicators for cardiac rehabilitation, says Low. In the future, hospitals would be able to measure what percentage of their eligible patient population is referred to cardiac rehabilitation and which actually go.

The goal is to have as many programs as possible participate so hospital administrators can compare their institution's scores with the average of all participating programs, explains Hamm.